Why treating Borderline Personality Disorder soo difficult??

[Anuwolf]

Maybe some of you guys could give me some insights to inspire me the reasons why some psychiatrists are complaining that treating a BPD is notoriously difficult? What makes so difficult into treating someone with BPD?

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[whopper]

One doctor told me this is how you diagnose someone with BPD.

"Did the patient piss you off?"

"yes"

"then the pt has borderline"

Now of course this isn't the way to do it. There's a DSM IV, etc.
But BPD are the types of people that "normal" people get annoyed by.

We of course are in a position where we must maintain objectiveness. To get upset at our patients is countertransference.
One thing frustrating with the condition, but you should not hold it against the patient is such patients are a large liabliity (some of them are looking for a lawsuit) and managed care does not want to pay for their treatment. So if you brush them away from inpatient therapy--which actually is the approrpiate thing to do in most cases so long as they are not suicidal, their fear of abandomment, histrionic characteristics and need for some emotional volatility may make them cause a scene.

Further, their diagnosis is often confused with other diagnosis. E.g. Borderlines can mimic Bipolar, MDD, or psychotic sx.

IMHO, with the exception of "affective" Borderlines, I feel that BPD is best handled by Psychology, not Psychiatry. I refer to those borderlines Managed care often will not pay for psychiatrists to use DBT, but will pay for psychologists or other therapists to do such and quite frankly, psychologists often have more training in this area than we do. Even affective Borderlines IMHO need psychological therapy, in fact may even need so more than psychiatric, but in affectives, meds can offer some benefit.

In short, in several spectrums, these patients do not often give us the good feelings we associate with the job. Financially, prognostically, diagnostically, compliance, quick satisfaction with a "quick cure" etc..they are difficult.

 

[Doc Samson]

compliance, quick satisfaction with a "quick cure"

This happens with other diagnoses?

 

[whopper]

Yeah--

bipolar mania or psychosis.

If the right med is given--you can have a patient out of the mania or psychosis in hours to about maybe 2-3 days.

I'd call that a quick cure, vs Borderline PD where the therapy can last years.
I'm sure you've gotten the few patients where you can't tell if they're borderline or not (vs an Axis I dx) and by the time you figured out they're BPD, the hospital is ticked off at you for keeping the patient in the unit for 3 days and now since you've dx'd with BPD managed care won't pay for it.

 

[Doc Samson]

Yeah--

bipolar mania or psychosis.

If the right med is given--you can have a patient out of the mania or psychosis in hours to about maybe 2-3 days.

I'd call that a quick cure, vs Borderline PD where the therapy can last years.
I'm sure you've gotten the few patients where you can't tell if they're borderline or not (vs an Axis I dx) and by the time you figured out they're BPD, the hospital is ticked off at you for keeping the patient in the unit for 3 days and now since you've dx'd with BPD managed care won't pay for it.

You can treat an acute episode of mania or psychosis in a relatively short period, just as you can stabilize a decompensated borderline. Either way, the chronic illness (Bipolar/Schizophrenia/Borderline) requires long-term care. To my mind, the immediate reward of a "cure" is best demonstrated by delirium... plus it's always kinda fun to point out what the internist/surgeon missed.

 

[whopper]

You are of course right---there is no actual cure for mental illness such as Bipolar or several of the psychosis (though not all). I was referring merely to the episode---but I didn't clarify it! Thanks!

 

[Demosthenes]

Maybe some of you guys could give me some insights to inspire me the reasons why some psychiatrists are complaining that treating a BPD is notoriously difficult? What makes so difficult into treating someone with BPD?

Maybe I'm showing my bias here, but I think the psychiatrist's attitude counts, too. If you go into a situation thinking, "Oh, the pt is BPD, there's nothing I can do for her, she's going to be difficult," then she's probably going to be difficult, and you're probably not going to be able to do anything for her.

Also, I've seen a lot of psychiatrists go the other way with the differential between BPD and bipolar/MDD/etc: make the BPD call before ruling out the Axis I dx. (At least, if it's a woman...) If the pt doesn't respond to the first SSRI, at the first target dose tried, there's a trend towards saying, "Ah, must be BPD, better look for signs..." After that, well, if you're looking for signs, you'll find them. (Also, seeing someone once every month or two, for half an hour, really doesn't give you enough time with a pt to make a good dx on this, IMO. Psychologists, seeing someone an hour a week, are probably in a better position to do that.)

As for what legitimately makes BPD so very difficult to work with, it's such an ingrained pattern of responses, and the BPD tends to see him/her-self as a victim of what other people are doing to her/him. It's hard to stop the emotional reaction long enough to say, "uh... Can you see how your actions might have had something to do with this?"

While it's probably hard either way, with a motivated BPD pt, you can get some good work done without too much hair loss. It's true, though, that psychology is a better place for it than psychiatry.

 

[Doc Samson]

It's true, though, that psychology is a better place for it than psychiatry.

Why?

 

[Demosthenes]

Why?

Maybe I should have said that it's my opinion that psychology is probably a better place for treating BPD? Much more accurate, at any rate. (Note to self: think first, type last...)

So, why do I think that? Partly my own bias: psychiatry for the biological side, psychology for the talk side. And while I think medication has a role to play in treating BPD, I see it more as something for talk therapy in a motivated pt. Preferably DBT, but not necessarily.

Again, that's because I look at it as something that's almost trained into their responses. (Don't ask, but I see a big place for some dog and horse training techniques in treating a lot of DOs. My own bias, but at least I'm usually aware of it.) Retraining those responses takes training, and meds -- no matter how helpful they are, and they are -- aren't going to do much to address the underlying issue.

By the way, is it just me, or are BPDs a little more likely to go off meds? "The Risperdal helped, so I stopped taking it."